Sunday, January 21, 2007

to tap...or not to tap...that is the question

Pleural effusions are collections of fluid in the pleural space (the space in between the lung and the chest wall). In the lateral decubitus film shown here, Arrow A shows the fluid layering out. Directly above the fluid is the right lung, somewhat squashed and displaced by the fluid. You can imagine that that would make it harder to breathe. Arrow B shows the normal width of the right hemithorax.

There has long been a debate between general pediatricians, pediatric surgeons and pediatric pulmonologists (as well as infectious disease specialists) as to how best to manage these cases. Option A is conservative management with IV/PO antibiotics. This is really only an option for kids who do not develop respiratory distress. Option B is diagnostic and therapeutic thoracentesis. Option C is a chest tube, which is really just an extension of Option B. Finally, Option D is surgical intervention with VATD, or video-assisted thoracoscopic decortication.

If you read the surgical literature, early VATD shortens hospital stay and duration of chest tubes. The rest of the literature is less conclusive. The management, as a result, depends on who you ask for a consult first, a surgeon or a pulmonologist. My bias might be obvious to some.

Over the last 3 weeks, we've had a 2yo, a 5yo and a 7mo with complicated pneumonias with effusions. Taken together, they illustrate the debate as it stands today (and as it has stood for as long as I can reckon):

*3yo admitted to the PICU: intubated electively for VATD (video-assisted thoracoscopic decortication), chest tube, IV antibiotics, extubated on day 6, transfered to the ward on day 8, home with 2wk course of PO antibiotics
*4yo admitted to the ward: IV antibiotics only x 5d with stable clinical course (no significant worsening of respiratory status and some improvement as illustrated by increased energy and less tachypnea), home with 2wk course of PO antibiotics
*9mo admitted to the ward: IV antibiotics x 3d with no improvement in clinical status, diagnostic thoracentesis showed exudative effusion, surgery consult, VATD, chest tube

The last child is still admitted. The chest tube is still in, post-op day 2 today. Apparently the pleural space was a bit of a mess of pus. I did the thoracentesis, my first. It's not a technically difficult procedure, but it was still pretty cool. For those not familiar with the term, the procedure consists of sticking a needle in between the ribs and drawing off fluid from the pleural space. The tricky parts are sticking a needle into an awake, crying baby and not aspirating the lung by sticking the needle in too far. If you are doing a therapeutic tap (i.e. drawing off as much fluid as you can get out), you can cause air to enter the space and create a pneuomothorax (literally air in the chest). If you draw off too much fluid, you can also cause hypotension. Not a good thing. I am happy to report that neither of those complications occured.


Flightfire said...

Cool! Thanks for that.

Paul said...

I think echo-guide drainage of the accumulated fluid using pig-tailed cahteter is a safe way to treat the condition. adequate drain is importane, especially in those infected cases.